Objectives: Given the significant burden of critical illness and high mortality in Low-Middle Income Countries (LMICs), ICU care could substantially improve patient outcomes in LMICs. No systematic approach is available to identify the perceived and actual challenges of developing and maintaining high-quality intensive care units in LMICs. This study aimed to use community-based group model building (GMB) as an intervention to evaluate the barriers and facilitators of establishing a Paediatric Intensive Care Unit (PICU) in LMIC. Design: A GMB workshop was conducted with 27 participants, representing all the stakeholders. The workshop objectives were: assess GMB as a tool for implementation planning in a lower resource clinical care setting; assess barriers and facilitators of PICU implementation as perceived by conference attendees; develop a shared vision for goals, processes, and challenges for the PICU. Setting: PICU at the Mercy James Center for Paediatric Surgery and Critical Care (MJC) within the established system of Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi

Few cancer therapeutic clinical trials have been conducted in low and middle-income countries (LMIC). As the global oncology community works to address this gap, it’s vital to incorporate implementation outcomes—and train future oncologists to do so—alongside traditional efficacy outcomes. This maximizes the impact of cancer research by delivering two complementary outcomes: efficacy and implementability. This study identified barriers to implementing cancer clinical trials in LMICs and determined core competencies essential for training global oncology clinical trialists. In fall 2024, participants at the Global Oncology Symposium at WashU were invited to participate in a ½ day workshop to explore the core components of an implementation science (IS) curriculum for global oncology practitioners and trainees. 30 participants (trainees (13), faculty/mentors (12), staff (3), donors (1), and policymakers (1) from the US and LMICs) engaged in structured activities. Small groups of 5–6 participants generated insights on barriers to implementing clinical trials in LMICs. These insights were organized into common themes for large group discussion. Building on these themes, participants brainstormed competencies or skills necessary to overcome these barriers. Responses were recorded on sticky notes, categorized into overarching themes, and summarized as core components of a global oncology IS curriculum. Key barriers to implementing cancer clinical trials in LMICs were grouped into the following themes: navigating regulations & bureaucracy, building partnerships, and managing resources and logistics. Participants identified 7 core competencies that should be included in a global oncology IS curriculum: 1) Flexible and open mindset 2) Technical skills and interdisciplinary knowledge 3) Community engagement 4) Skills to build and maintain partnerships 5) Designing for sustainability 6) Regulatory affairs and 7) Political engagement and advocacy. The findings underscore the importance of an interdisciplinary and culturally sensitive approach to global oncology IS training. A curriculum grounded in the identified competencies can equip global oncologists to design and execute effective and implementable clinical trials, ultimately improving cancer care delivery worldwide. Future efforts should build on this work to develop, systematically pilot, and refine a comprehensive curriculum for global oncology training programs. Thomas Odeny, Betsy Abente, Ellis Ballard, Sara Malone, Rachel Matsumoto, Patti Gravitt. Designing the Future: An Implementation Science Curriculum for Globally Oriented Oncologists and Trainees [abstract]. In: Proceedings of the 13th Annual Symposium on Global Cancer Research; 2025 Sep 16. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2025;34(12_Suppl):Abstract nr 87.

Child maltreatment (CM) is a significant and global public health concern with a complex array of causes and consequences. Identifying the most impactful modifiable factors at all levels of the ecosystem is a significant challenge for policymakers, practitioners, students, and researchers trying to grasp the multidisciplinary literature that accompanies such complex and dynamic problems. This article describes the process of creating a public facing dynamic literature map using a novel application of Group Model Building (GMB), as systems science method, with academic and field experts to develop a qualitative map of hypothesized paths to and following CM and then link this to empirical findings. The goal of the "map" was to address the problem of creating a publicly accessible summary of knowledge across disciplines that helps identify constructs and paths that may have received greater or lesser research attention so that it reflects a high level, and updateable, summary of what is known and gaps for further research. This multi-year process creates an accessible tool through use of electronic interactive visual mapping software in the hopes of better informing practice, policy, and research innovation. The present article provides a summary of the process and introduction to an Alpha version of this electronic map.

BACKGROUND:The deteriorating mental health of children and young people in the United Kingdom poses a challenge that services and policy makers have found difficult to tackle. Kailo responds to this issue with a community-based participatory and systemically informed strategy, perceiving mental health and well-being as a dynamic state shaped by the interplay of broader health determinants. The initiative works to explore, define and implement locally relevant solutions to challenges shaping the mental health and well-being of young people. Kailo unfolds in three stages within each locale. These stages encompass: "early discovery", "deeper discovery and co-design" and "implementation". This document delves into the participatory group model building and design protocol occurring in the "deeper discovery and co-design" stage of the project. METHODS:Participatory methods, such as group model building, are effective in articulating and building consensus on complex issues like the social determinants of adolescent mental health. This paper describes the protocol for application of group model building within the Kailo design process to develop causal loop diagrams and pinpoint leverage points for improving adolescent mental health. It also suggests a method for considering modifications to delivery within a unique project context and in alignment with participants' needs. This paper sets out to define the approach and clarify the objectives these engagements aim to fulfil. The method adapts existing group model building (GMB) protocols for use in a community setting. The engagements will involve groups of local young people and existing community members. To assess the success of the session's implementation post-delivery, the study utilizes existing frameworks for fidelity evaluations, which define a core and flex model. DISCUSSION:The method described enables an integration of diverse local understandings of complex processes which provides a platform for creating co-designed interventions. This protocol can be used to further strengthen research and design through incorporating complexity and participation into the formulation of contextually relevant policies and practices. The strengths and limitations of the approach are discussed.

Background:Peru's progress in reducing stunting has stagnated since 2018, while the country is facing increasing levels of overnutrition, leading to a double burden of malnutrition. However, this shift in nutrition burden is not reflected in Peru's nutrition policy agenda. This study aims to identify leverage points for actions against population-level double burden of malnutrition in Peru. Methods:We developed a system dynamics model that simulates changes in overweight and stunting over time in Peru through changes in food system drivers. The model was conceptually informed by policymakers, practitioners and community members in Peru and used quantitative and qualitative data from secondary sources and published literature. Findings:The model indicated that several overnutrition policies, including policies targeting food availability and affordability, may decelerate but not halt the increase of overweight in the country, mainly due to industry resistance. However, in the long term, the reallocation of resources towards overnutrition policies may inadvertently hinder progress towards stunting targets. Transforming nutrition policy governance, from siloed overnutrition and undernutrition policies towards a common policy framework against the double burden of malnutrition was the only modelled scenario that halted the rise in overnutrition, while keeping Peru on course to reach its stunting goals. Interpretation:Transition away from policy landscapes that focus on single nutrition outcomes towards synergistic actions that target malnutrition in all forms is a long-term solution towards achieving global nutrition goals. Such policy transitions are especially important in low and middle-income countries like Peru, which are affected by the double burden of malnutrition. Funding:This study was supported by a research grant from the Biotechnology and Biological Sciences Research Council (BBSRC) (grant reference: BB/T009004/1).

Current approaches to identifying the impacts of structural racism on human development focus on downstream consequences or developmental outcomes rather than the upstream processes that create and perpetuate those negative consequences. Yet, the hallmarks of complex problems like structural racism include feedback relationships linking factors, path dependence, dynamics, non-linear effects, time delays, counterintuitive, and policy resistance. Pollutant exposures and their resulting deleterious effects on child health and development are among the downstream effects of structural racism. System dynamics modeling, a branch of systems science, provides developmental and environmental researchers with approaches to analyze complexity and integrate evidence from multiple disciplines through a common language and visualization of systems of structural racism. In this commentary, we introduce core tenets of system dynamics modeling as means of delineating the institutional and structural processes of environmental racism from the measurable consequences to child development; highlight specific implications of system dynamics modeling for developmental sciences; use the ongoing environmental health crisis in Flint, MI as a case example of how system dynamics modeling can be used to examine the impacts of structural racism on child development.

Background Peru is facing a double burden of malnutrition (DBM), characterized by the co-existence of undernutrition and overnutrition. Double-duty actions that concurrently target common drivers of undernutrition and overnutrition, while ensuring no unintended side effects, are recommended to effectively address the DBM. To understand these complex common mechanisms and design context-specific double-duty actions, there is a need for participatory systems approaches. This paper provides a case study of applying a community-based system dynamics approach to capture stakeholder perspectives of food system drivers of the DBM in two regions in Peru. Methods We implemented a multi-stage community-based system dynamics approach, which included processes for research capacity building for systems approaches, and the designing, piloting, and implementation of stakeholder workshops. A total of 36 stakeholders, representing diverse perspectives, participated in five group model building workshops. Stakeholder views are presented in a causal loop diagram that showcases the feedback mechanisms between key food system drivers of overweight and stunting in Peru. Results The causal loop diagram highlights that prioritization of undernutrition over overnutrition in the policymaking process, due to Peru’s historically high levels of undernutrition, may undermine action against the DBM. It also describes potential mechanisms of unintended impacts of undernutrition policies on the DBM in Peru, including impacts related to within-family distribution and quality of food provided through food assistance programs, and unintended impacts due to regional dynamics. Conclusions This paper highlights the importance of a participatory approach to understand local needs and priorities when recommending double-duty actions in Peru and shares practical methodological guidance on applying participatory systems approaches in public health.

BACKGROUND:The combined effects of multiple environmental toxicants and social stressor exposures are widely recognized as important public health problems, likely contributing to health inequities. However, US policy makers at state and federal levels typically focus on one stressor exposure at a time and have failed to develop comprehensive strategies to reduce multiple co-occurring exposures, mitigate cumulative risks and prevent harm. This research aimed to move from considering disparate environmental stressors in isolation to mapping the links between environmental, economic, social and health outcomes as a dynamic complex system using children's exposure to neurodevelopmental toxicants as an illustrative example. Such a model can be used to support a broad range of child developmental and environmental health policy stakeholders in improving their understanding of cumulative effects of multiple chemical, physical, biological and social environmental stressors as a complex system through a collaborative learning process. METHODS:We used system dynamics (SD) group model building to develop a qualitative causal theory linking multiple interacting streams of social stressors and environmental neurotoxicants impacting children's neurodevelopment. A 2 1/2-day interactive system dynamics workshop involving experts across multiple disciplines was convened to develop the model followed by qualitative survey on system insights. RESULTS:The SD causal map covered seven interconnected themes: environmental exposures, social environment, health status, education, employment, housing and advocacy. Potential high leverage intervention points for reducing disparities in children's cumulative neurotoxicant exposures and effects were identified. Workshop participants developed deeper level of understanding about the complexity of cumulative environmental health risks, increased their agreement about underlying causes, and enhanced their capabilities for integrating diverse forms of knowledge about the complex multi-level problem of cumulative chemical and non-chemical exposures. CONCLUSION:Group model building using SD can lead to important insights to into the sociological, policy, and institutional mechanisms through which disparities in cumulative impacts are transmitted, resisted, and understood.

Much attention and concern has been raised recently about bias and the use of machine learning algorithms in healthcare, especially as it relates to perpetuating racial discrimination and health disparities. Following an initial system dynamics workshop at the Data for Black Lives II conference hosted at MIT in January of 2019, a group of conference participants interested in building capabilities to use system dynamics to understand complex societal issues convened monthly to explore issues related to racial bias in AI and implications for health disparities through qualitative and simulation modeling. In this paper we present results and insights from the modeling process and highlight the importance of centering the discussion of data and healthcare on people and their experiences with healthcare and science, and recognizing the societal context where the algorithm is operating. Collective memory of community trauma, through deaths attributed to poor healthcare, and negative experiences with healthcare are endogenous drivers of seeking treatment and experiencing effective care, which impact the availability and quality of data for algorithms. These drivers have drastically disparate initial conditions for different racial groups and point to limited impact of focusing solely on improving diagnostic algorithms for achieving better health outcomes for some groups.

Participatory system dynamics modeling provides tools to represent and improve mental models through stakeholder participation. A hallmark of this approach is the creation and management models as boundary objects. With a proliferation of participatory modeling in diverse contexts, new methodological challenges have emerged around the role of language and translation. This article identifies a gap in the literature around the challenge of language, literacy, and linguistic translation in participatory modeling practice and examines examples from an emerging body of international practice. The authors present a case study that uses visuals to bridge multiple linguistic and literacy divides in workshops in rural India. The authors delineate a preliminary set of language configurations for boundary-object engagement to clarify design choices of modelers and facilitators. They close with a discussion of the need to assess and document facilitation and language choices and propose opportunities to strengthen practical guidance for the field. (c) 2021 System Dynamics Society.

BACKGROUND:Group model building (GMB) is a method to facilitate shared understanding of structures and relationships that determine system behaviors. This project aimed to determine the feasibility of GMB in a resource-limited setting and to use GMB to describe key barriers and facilitators to effective acute care delivery at a tertiary care hospital in Malawi.METHODS:Over 1 week, trained facilitators led three GMB sessions with two groups of healthcare providers to facilitate shared understanding of structures and relationships that determine system behaviors. One group aimed to identify factors that impact patient flow in the paediatric special care ward. The other aimed to identify factors impacting delivery of high-quality care in the paediatric accident and emergency room. Synthesized causal maps of factors influencing patient care were generated, revised, and qualitatively analyzed.RESULTS:Causal maps identified patient condition as the central modifier of acute care delivery. Severe illness and high volume of patients were identified as creating system strain in several domains: (1) physical space, (2) resource needs and utilization, (3) staff capabilities and (4) quality improvement. Stress in these domains results in worsening patient condition and perpetuating negative reinforcing feedback loops. Balancing factors inherent to the current system included (1) parental engagement, (2) provider resilience, (3) ease of communication and (4) patient death. Perceived strengths of the GMB process were representation of diverse stakeholder viewpoints and complex system synthesis in a visual causal pathway, the process inclusivity, development of shared understanding, new idea generation and momentum building. Challenges identified included time required for completion and potential for participant selection bias.CONCLUSIONS:GMB facilitated creation of a shared mental model, as a first step in optimizing acute care delivery in a paediatric facility in this resource-limited setting.

Background: The combined effects of multiple environmental toxicants and social stressor exposures are widely recognized as important public health problems, likely contributing to health inequities. However cumulative environmental health risk and impacts have received little attention by US policy makers at state and federal levels to develop comprehensive strategies to reduce these exposures, mitigate cumulative risks and prevent harm. An area for which the inherent limitations of current approaches to cumulative environmental health risk are well illustrated is children's neurodevelopment which exhibits dynamic complexity, intergenerational effects and interdependent and causally linked nature of multiple factors. Systems science methods enable investigators to examine the dynamic relationships of variables at multiple levels of analysis simultaneously, while also studying the impact of the non-linear behavior of the system as a whole over time. Thus we contend that a systems approach, specifically system dynamics, may be better suited for devising policy solutions to address cumulative effects of multiple chemical, physical, biological and social environmental stressors. Methods: We convened a 2 1/2-day system dynamics workshop involving experts across multiple disciplines to formally describe the multiple interacting streams of social stressors and environmental neurotoxicants impacting children's neurodevelopment through the use of qualitative system maps and formal system dynamics simulation models. Results: An initial system dynamics causal map was developed, incorporating feedback mechanisms relevant to diverse disciplines. Potential high leverage intervention points for reducing disparities in children's cumulative neurotoxicant exposures and effects were identified. Workshop participants developed deeper level of understanding about the complexity of cumulative environmental health risks, increased their agreement about underlying causes, and enhanced their capabilities for integrating diverse forms of knowledge about the complex multi-level problem of cumulative chemical and nonchemical exposures. Conclusion: We conclude that this approach successfully enabled a multidisciplinary group to explore relationships in a complex dynamic system.

BACKGROUND:Frameworks such as the WSCC model provide evidence-based guidance for addressing school health at the school, district, and regional level. However, frameworks do not implement themselves; they require the mobilization and collaboration of stakeholders within communities and an understanding of the unique resources and barriers within each context. Furthermore, addressing school health presents a complex systems problem. METHODS:Community-based system dynamics (CBSD) is a participatory approach for engaging communities in understanding and changing complex systems. We used a descriptive multiple case study design to evaluate how and why CBSD was used as a tool for stakeholders to engage with the complexity of school health. RESULTS:We analyzed 3 cases to understand how these methods were used to enhance collaboration, analysis, and community action at multiple levels, including in 2 school districts, with a city-wide stakeholder committee, and with a group of high school students. CONCLUSIONS:Community-based system dynamics presents a promising approach for building shared language and ownership among stakeholders, tailoring to local community contexts, and mobilizing stakeholders for action based on new system insights. We close with a discussion of unique opportunities and challenges of expanding the use of CBSD in the field of school health.

BACKGROUND The Whole School, Whole Community, Whole Child (WSCC) model is an evidence-based comprehensive framework to address health in schools. WSCC model use improves health and educational outcomes, but implementation remains a challenge. METHODS Working with 6 schools in 2 districts in the Midwest, we used a mixed-methods approach to determine the people, systems, and messages needed to activate WSCC implementation. We report on social network analysis and message testing findings and research translation to develop the Healthy Schools Toolkit. RESULTS Social networks for both districts included more than 150 individuals. Both demonstrated network densities less than half of the desirable threshold, with evidence of clustering by role and minimal cross-school relationships, posing challenges for WSCC implementation. Across stakeholder groups, messages that emphasize empathy, teamwork, and action were well-received, especially when shared by trusted individuals through communication channels that align with stakeholder needs. CONCLUSIONS The Healthy Schools Toolkit provides an example of a translational product that helps to bridge research with practice. With features that highlight 6 design principles, the toolkit provides complementary activities that schools and districts can use as they plan for integration of the WSCC model.

The purpose of this study was to develop a qualitative and socioculturally tailored systems model of childhood obesity in the Chinese American community in Manhattan's Chinatown. We utilized group model building (GMB) methodology as a form of participatory systems modeling. The study was conducted in Manhattan's Chinatown community. We recruited 16 Chinese American adults from the community. GMB workshops engendered a causal loop diagram (CLD), the visualization of a complex systems model illustrating the structures, feedbacks, and interdependencies among socioculturally specific pathways underlying childhood obesity, in Manhattan's Chinatown community. The analysis of CLD revealed that participants considered the following factors to influence childhood obesity: (1) traditional social norms affecting body image, how children are raised, parental pressure to study, and trust in health of traditional foods; (2) grandparents' responsibility for children; (3) limited time availability of parents at home; and (4) a significant amount of children's time spent indoors. GMB represents a novel method to understand the complexity of childhood obesity in culturally specific populations and contexts. The study identified sociocultural subsystems that may underlie the development and perpetuation of childhood obesity among Chinese American children. Insights from the study can be useful in the design of future empirical studies and interventions.

ObjectivesTo generate system insights on patient and provider levers and strategies that must be activated to improve hospital-based smoking cessation treatment.DesignMixed methods study including a series of in-depth group model building sessions, which informed the design of an online survey completed by healthcare providers and a structured interview protocol administered at the bedside to patients who smoke.SettingLarge, tertiary care hospital in the Midwestern United States.ParticipantsGroup model building: 28 healthcare providers and 22 previously-hospitalised patients;Online survey: 308 healthcare providers;Bedside interviews: 205 hospitalised patients.Primary and secondary outcome measuresHypothesis-generating, participatory qualitative methods informed the examination of the following quantitative outcomes: patient interest versus provider perception of patient interest in smoking cessation and treatment; patient-reported receipt versus provider-reported offering of inpatient smoking cessation interventions; and priority ratings of importance and feasibility of strategies to improve treatment.ResultsSystem insightsincluded patients frequently leaving the floor to smoke, which created major workflow disruption.Leverage pointsincluded interventions to reduce withdrawal symptoms, andaction ideasincluded nurse-driven protocols for timely administration of nicotine replacement therapy. Quantitative data corroborated system insights; for instance, 80% of providers reported that patients frequently leave the floor to smoke, leading to safety risks, missed assessments and inefficient use of staff time. Patients reported significantly lower rates of receiving any smoking cessation interventions, compared with provider reports (mean difference=17.4%–33.7%, p<0.001). Although 92% of providers cited patient interest as a key barrier, only 4% of patients indicated no interest in quitting or reducing smoking.ConclusionsEngaging hospital providers and patients in participatory approaches to develop an implementation strategy revealed discrepant perceptions of patient interest and frequency of hospital-based treatment for smoking. These findings spurred adoption of standardised point-of-care treatment for cigarette smoking, which remains highly prevalent yet undertreated among hospitalised patients.

Little is known about the mechanisms through which neighborhood-level factors (e.g., social support, economic opportunity) relate to suboptimal availability of healthy foods in low-income urban communities. We engaged a diverse group of chain and local food outlet owners, residents, neighborhood organizations, and city agencies based in Baltimore, MD. Eighteen participants completed a series of exercises based on a set of pre-defined scripts through an interactive, iterative group model building process over a two-day community based workshop. This process culminated in the development of causal loop diagrams, based on participants' perspectives, illustrating the dynamic factors in an urban neighborhood food system. Synthesis of diagrams yielded 21 factors and their embedded feedback loops. Crime played a prominent role in several feedback loops within the neighborhood food system: contributing to healthy food being "risky food," supporting unhealthy food stores, and severing social ties important for learning about healthy food. Findings shed light on a new framework for thinking about barriers related to healthy food access and pointed to potential new avenues for intervention, such as reducing neighborhood crime.

Access to education has been the central tenet of the Millennium Development Goal 2, which focused strongly on increasing enrolment yet failed to promote education quality and equity and address contextual complexities that sustain exclusion. As a consequence, many children are not learning. There is growing recognition that effective, efficient and equitable education for all will not be achieved without better accountability. The present paper details innovative methods for strengthening the learning process through better social accountability. The paper defines and tests in rural schools of Afghanistan and Pakistan a community-based system dynamics protocol using participatory group model building (GMB) techniques. We tested the protocol with two groups of teachers and one group of children, with the three produced causal loop diagrams highlighting factors that influence learning in the classroom from the perspectives of the participants. The sessions showed interest, engagement, quick mastery of how GMB methods work and clear understanding of how the current classroom system hinders learning for many students. Researchers found that large autonomy and initiative could be left to the workshop participants, keeping the facilitator's role to one of explaining the method and asking clarification about causal relations.

We discuss the design, implementation, and results of a collaborative process designed to elucidate the complex systems that drive food behaviors, transport, and health in Latin American cities and to build capacity for systems thinking and community-based system dynamics (CBSD) methods among diverse research team members and stakeholders. During three CBSD workshops, 62 stakeholders from 10 Latin American countries identified 98 variables and a series of feedback loops that shape food behaviors, transportation and health, along with 52 policy levers. Our findings suggest that CBSD can engage local stakeholders, help them view problems through the lens of complex systems and use their insights to prioritize research efforts and identify novel solutions that consider mechanisms of complexity.

Aims & Objectives: The introduction of high-quality pediatric critical care medicine (PCCM) in resource-limited settings presents multiple challenges, including the need to coordinate medical care provided by different stakeholders to ensure successful service provision. We aimed to test the use of community-based group model building (GMB) as an intervention to address challenges faced in opening a new Pediatric Critical Care Unit (Mercy James Center for Pediatric Surgery and Critical Care (MJC)) in Blantyre, Malawi. Methods We used GMB to engage multiple stakeholders related to MJC in the process of developing a common vision and language for delivering high-quality PCCM. Two facilitators trained in community-based system dynamics designed and led a two-day GMB workshop in Blantyre in October 2017. Results The participatory workshop exposed the divergent goals and challenges that various stakeholder groups had with respect to the initiation of a new PCCM service at MJC. We developed a causal model (Figure 1) depicting the interrelationships between factors influencing the development of a high-quality PCCM service as a boundary object to negotiate these disparate viewpoints. Group review of the model led to greater consensus and willingness to engage in collaborative problem-solving to achieve common goals. Stakeholders identified strategies to address weaknesses in the causal model for future implementation (Table 1). Figure 1. Causal Model Table 1. Implementation Strategies Conclusions GMB is valuable as a participatory process in addressing various challenges in the implementation and sustainability of high-quality PCCM in resource-limited settings. The next phase involves implementing several impactful strategies to enhance the delivery of PCCM in MJC.